From the Desk of Gus Mueller
Most all audiologists seem to agree to call a hearing aid fitting, a hearing aid fitting. What they don’t all agree on, however, is when the hearing aid fitting is finished? When the patient says “sounds good?” When the probe-mic measures show a fit to prescriptive targets? When the orientation on use and care of the instruments is completed? When post-fitting tweaking is finished? When the COSI goals have been met? At the end of 30 days of hearing aid use?
What if research told us, that for at least some of our patients, post-fitting auditory training would improve benefit and satisfaction with hearing aids? Would that then still be part of the “fitting?” The discussion of auditory training is not new to 20Q, as two years ago we invited Nancy Tye-Murray to review current thinking on the topic (read her 2016 20Q here). Her article was met with enthusiasm, and so we’ve invited her back to expand on her thoughts, and bring us up to date with what has been happening lately.
Nancy Tye-Murray, PhD, is a Professor in the Department of Otolaryngology at Washington University School of Medicine where she directs the Audiovisual Speech Perception Laboratory. She is also an Adjunct Professor at the University of Canterbury in New Zealand, where she has served as an Erskine Fellow. She is the former president of the Academy of Rehabilitative Audiology and former Hearing Editor for the Journal of Speech-Language-Hearing Research.
The fact that Dr. Tye-Murray has received over 30 years of continuous funding from the National Institutes of Health attests to the caliber of her research. Through her many articles and books she also is well known among clinicians and students; most notable is her book Foundations of Aural Rehabilitation: Children, Adults, and Their Family Members, now in its 5th Edition. Related to her years of research with auditory training, she recently launched clEAR (customized learning: Exercises for Aural Rehabilitation; TM), an Internet business that provides customized auditory brain training to people who have hearing loss (www.clearworks4ears.com).
In this intriguing article, Nancy raises several important issues regarding auditory training and its role in the new dispensing world. She also points out that not all auditory training is the same, and reminds us that an extra shot of dopamine can be a good thing!
Gus Mueller, PhD
Browse the complete collection of 20Q with Gus Mueller CEU articles at www.audiologyonline.com/20Q
20Q: A Perfect Storm for Auditory Brain Training
After this course, readers will be able to:
- Define and describe auditory brain training.
- Explain why the current healthcare landscape may support audiologists incorporating auditory brain training into clinical practice.
- Describe components of successful auditory brain training including candidates, compliance, patient education, program considerations, and other factors.
1. First, what do you mean when you say auditory brain training and how is that different from traditional auditory training?
Since the end of the nineteenth century, auditory training has been described as being either analytic or synthetic, or as being some combination of both. Analytic training focuses the listener’s attention on recognizing the units of speech, such as phonemes in syllable and word context, whereas synthetic training focuses the listener’s attention on comprehending the gist of a message. Auditory brain training is a variant of auditory training and incorporates both analytic and synthetic training activities, but it also incorporates cognitive tasks that develop those mental skills that are necessary for understanding speech no matter what is being said, mental skills that include auditory attention, auditory processing speed, and auditory working memory. For example, if a person has just received a new hearing aid, auditory brain training “recalibrates” the brain for listening. Changes in brain structures have most likely occurred gradually over time because of decreasing and deteriorating auditory stimulation. When the person suddenly receives an amplified, spectrally shaped speech signal, the brain needs to undergo reorganization. Auditory brain training can accelerate and complement this process and promote sensory neuroplasticity (e.g., Kraus & White-Schwoch, 2015).
2. Why do you consider today’s world a perfect storm for auditory brain training?
I use the term "a perfect storm" in a metaphorical sense, meaning that a combination of events is coming together to cause an amazing and a once-in-a-generation opportunity. The landscape of audiology is evolving rapidly and integrating auditory brain training into clinical practice at this moment in time is ideal for three reasons.
3. Okay, I’ll bite - what are those three reasons?
First, it allows audiologists to distinguish themselves from the competition; second, it is a source of untapped revenue; and third, it is a means to provide patients with customized hearing healthcare.
4. Auditory training has been around a long time. What’s happening to change things now?
According to Brian Taylor (2018), audiologists generate a whopping 80 percent of their practice revenue from selling hearing aids. He discusses the “strong retail bent” of our profession and that “this side of [audiology] centers on the sale of hearing aids, which are more apt to be perceived by the public as consumer electronic products than as medical devices (P. 16).” Here’s the rub: with big box stores such as Costco’s and Sam’s selling hearing aids at a much cheaper price point, and over-the-counter hearing aids looming on the horizon, many audiologists are asking themselves, "How can I distinguish myself as a hearing healthcare professional and not simply a provider of listening devices?" I often use the analogy of a knee replacement and physical therapy. Just as an orthopedic surgeon recommends physical therapy after giving a patient a knee replacement, an audiologist can recommend auditory brain training, a kind of listening therapy, to patients who receive hearing aids. Moreover, if a patient has a hearing loss but is not ready for hearing aids, for whatever reason (e.g., doesn’t want to incur the psychological cost of admitting getting older; doesn’t believe that he or she has hearing loss bad enough to warrant the expense of hearing aids), the audiologist now has another option for treatment.
5. So you’re saying that this brain training is not just for my hearing aid patients?
Correct. Auditory brain training can help the patient maximally use residual hearing and may even be an effective way to draw patients’ attention to what they are and are not hearing. For example, I had one patient who was not ready for hearing aids and after engaging in clEAR auditory brain training (customized learning: Exercises for Auditory Training), he went on to buy two hearing aids. Through training, he realized the magnitude of his listening problems because the feedback from the program’s auditory brain training games showed him how much he was missing. Moreover, he had developed trust in our university clinic, realizing that we were first and foremost hearing healthcare professionals and not simply hearing aid salespeople. Many computerized programs allow the audiologist to follow the patient’s progress through feedback charts and to provide coaching and support through a messaging system. This personalized contact further enhances the experience of hearing healthcare and fosters trust. By providing auditory brain training as part of the service, an audiologist can say, “I’m going to provide you with listening therapy as well as amplification, and I’m going to be a part of your hearing healthcare journey, beginning with diagnostics, through receipt of a hearing aid, and then throughout your adjustment and learning period.”
6. Do you have data supporting your assertion that patients want their audiologist to be part of their hearing healthcare journey?
We conducted a study in 2012 involving 93 patients who completed auditory brain training for 16 sessions. At the end of their training, we asked them to tell us what they liked best about their participation in the study, and one of the top answers was, ongoing support from an audiologist (Tye-Murray et al., 2012). I also have anecdotal evidence from my own patient load. For example, one patient described herself as being in a “dark place” because of her hearing difficulties before she enrolled in our auditory brain training program. She’s been training for three months now and I have messaged her about her progress throughout her training. She recently messaged, “Thanks a bunch—I’m impressed by the specialized attention.” Last week she returned from a vacation and messaged that she heard better in noisy restaurants and feels she is seeing the “daylight at the end of the tunnel”. Perhaps the most telling stamp of approval is that when her 3-month subscription to the training program expired, she opted to extend it to one year.
7. I’ve always heard that computerized auditory training programs have been met with poor compliance. Not true?
Not true, at least not true for all. We have a compliance rate as high as 95% (Tye-Murray et al., 2012). Three ingredients comprise a program’s secret sauce of success, and I believe this is true for any auditory training program out there. The first is that patients want a lesson plan. You cannot just sign them up and then send them home to train willy-nilly; they will not do it. The clEAR program sends them a plan each week that suggests which of its computerized auditory brain training activities to play, how long to play each one, and importantly, the reason why they are playing them at this point in time.
8. What do you mean by “reason they are playing?”
There are different plans for different listening goals; e.g., there is a plan for the patient who is adjusting to a new hearing aid and there is a plan for the patient who wants to recognize speech better in the presence of background noise. One size does not fit all, and training should be tailored to suit an individual’s listening challenges. The second ingredient is that training must be engaging and pleasurable. I do not care if you are three years old or ninety-three, if you are bored silly, you are not going to learn. It was not that many years ago when students in a graduate level class of aural rehabilitation might be working with a patient in a practicum, and would cover their mouths with a mesh screen and say, “Bah-Bah, are those the same or different? Bah-Mah, are those the same or different?” How boring! I yawn just thinking about it. Finally, and most importantly, an essential ingredient is the ongoing oversight by an audiologist. Patients want to know that someone is paying attention to their training practices and they want to know that someone cares about their progress. Never underestimate the power of the human touch.
9. Earlier you mentioned that auditory brain training is a way to generate revenue? Seriously - auditory brain training can be a money-maker?
I appreciate that at the end of the day, no matter how altruistic he or she might be, the audiologist has to make money in order to stay in business. I just talked about the computer-based games, the feedback charts, and the messaging system that clEAR uses. Other commercially available programs have similar features. These are quick and easy ways for the audiologist to provide customized auditory brain training without expending much time in doing so. After all, time is money.
10. True, but where is the revenue coming from?
Let’s say that an audiologist in private practice or in a hospital setting fits twenty patients a month with hearing aids. Imagine the extreme case where every one of these patients opted to subscribe through their audiologist to an online auditory brain training program. In at least one program, the suggested retail price is $150 and the wholesale price to the audiologist is $75, meaning a profit of $75 for every subscription sold. In this extreme case, the audiologist stands to realize $18,000 of untapped annual revenue. As my grandmother used to say, we aren’t talking poppy seeds here.
One program is changing pricing so that the retail price will be going from $150 for a three-month set subscription to $24.99 a month, with the option of recurring monthly charges. Even if the retail pricing of the program is low, the proposed Audiology Patient Choice Act, which I’ll talk about shortly, will allow audiologists to bill Medicare for providing aural rehabilitation and auditory brain training. This means that audiologists could bill using existing CPT codes such as 92626, 92627, and 92507, which are codes currently used by speech-language pathologists.
11. What about those patients who already have hearing aids or who are not interested in obtaining aids?
Factor into the equation those people who have hearing aids but are not entirely happy with their performance, for example, the patient who complains of listening in noise, as well as those people who have hearing loss but who are not yet ready for hearing aids (perhaps as much as 70% of people with hearing loss). Considering these two additional factors, the revenue number increases exponentially.
12. So auditory brain training can provide a supplemental or even an alternative intervention and revenue source?
I sometimes use the analogy of Starbucks when talking to audiologists in private practice. You most likely go into Starbucks for a cup of coffee, but it is nice to have the option of buying tea instead of a java and it is nice to have the option of buying coffee-related paraphernalia. A subscription to an auditory brain training program is another commodity in an audiologist’s product offerings.
13. What about the patients who are just not willing to pay even a modest amount?
Here again is where I return to the concept of a perfect storm brewing. Right now, legislation is pending before the Senate called the Audiology Patient Choice Act and introduced on March 20, 2018, by Elizabeth Warren (D-MA) and Rand Paul (R-KY). The Audiology Patient Choice Act would allow audiologists to bill Medicare for auditory rehabilitation services, including auditory brain training, which is a service that will help improve either aided or unaided hearing. My hope is that by this time next year, audiologists will be able to receive reimbursement for providing auditory brain training.
14. Why is the topic of comprehensive hearing healthcare especially timely?
The broad brush answer is that we are talking about all patients who have hearing loss and who are interested in diminishing their current hearing-related communication problems, whether or not they use hearing aids.
The public is increasingly aware of the consequences of untreated hearing loss, thanks in large part to research coming out of Johns Hopkins University (Lin et al., 2011). The research determined that people are more likely to experience age-related cognitive decline if their hearing loss goes untreated. The findings have literally been splashed on newspaper headlines across the country, so the public is becoming much more receptive to the idea of “exercising” their cognitive auditory abilities as well as their peripheral listening skills through systematic, formal training.
15. This all sounds good, but I recall hearing that some researchers have shown auditory training is effective but some have not. Why do we have this ambiguity?
The term auditory training is a catch-all term that is pasted on an array of programs that differ in both philosophical approach and actual training activities. For example, the kind of training I provide to my patients trains only with meaningful speech, emphasizes the development of cognitive auditory skills and is gamified so to heighten the enjoyment of training (e.g., Tye-Murray, Spehar, Barcroft, & Sommers, 2017). By contrast, other programs emphasize nonsense syllable training in drill format so as not to distract patients through the gaming process and to emphasize sound discrimination (e.g., Moore, Rosenberg, & Coleman, 2005). Some programs present drill training on the most frequently used words of the English language in a rote format (e.g., Humes et al. (2009) and some present only sentence training, again in a rote format (e.g., Boothroyd, 2008).
16. It sounds like we all are not talking the same language?
Exactly. Readers may see the term “auditory training” in two different research articles and believe it means the same type of intervention in both investigations, although in reality, they might be quite different. In essence, as a profession, we have apples and oranges and we are bundling them under the rubric of fruit. The inconsistent findings of the effectiveness of auditory training and the ambiguity about what we mean when we use the term auditory training probably contribute to why auditory training and auditory brain training is a rarity in many practices. On the surface, it is impossible to make a blanket statement about effectiveness, which detracts from the gold standard of evidence-based practice. When I read some of the studies that show no benefit, I am typically not surprised because if you read the methods section, the researchers most likely have bored their participants silly with repetitive drill activities presented for hours on end. Of course, it is hard to learn when you are dozing or daydreaming.
17. You keep coming back to the idea that training has to be engaging. What is the rationale for this?
My answer comes right out of a Neuroscience 1-0-1 textbook. The rationale is as follows: 1) Playing computer games is pleasurable; 2) pleasure causes the brain to increase dopamine production; dopamine is a neurotransmitter that plays a messaging role between brain cells; 3) increased levels of dopamine in the brain enhances neural plasticity; 4) perceptual learning can occur in the presence of enhanced neural plasticity; and 5) adults with hearing loss are more likely to benefit from perceptual training if they are having fun than if they are performing rote training tasks.
18. That seems logical. Why do the training stimuli have to be meaningful, and not, say, nonsense syllables?
In meaning-based training, all training stimuli carry meaning and participants must attend to the meaning of a word or a sentence in order to respond correctly to a training stimulus. This is as opposed to nonsense syllable training, where participants listen to nonsense syllables, and discrimination activities, where participants must decide of two stimuli are the same or different, even if they have no idea of the words being spoken. The rationale comes from the second-language learning literature, which has shown that learners must attend to the sounds of the language in the context of meaning and the communicative content that the sounds convey in order to acquire the language (Barcroft, Sommers, & Tye-Murray, 2007).
19. What does the research say about gamified, meaning-based auditory brain training?
This kind of auditory brain training has been shown to be beneficial. It has been shown to improve speech discrimination (e.g., Barcroft, Spehar, Tye-Murray, & Sommers, 2016; Tye-Murray et al., 2017), to reduce perceptual effort (Sommers, Tye-Murray, Barcroft, & Spehar, 2015) and to increase confidence in engaging in conversations (Tye-Murray et al., 2012). If you receive auditory brain training with the speech of a loved one, such as a spouse, you can even improve your ability to recognize that person’s speech (Tye-Murray et al., 2017).
20. Okay, I’m ready to start! How do I implement this into my practice?
There are two critical components for implementing auditory brain training into your practice. First, you need the language to describe it to your patients and second, you need to be able to get your patients started quickly and there is simply not enough time in many audiologists’ workday to describe the benefits of auditory training and training procedures in-depth. At clEAR, we provide audiologists with a three-piece “educational package”. The first piece is a simple postcard that describes the three phases of the hearing healthcare journey: Diagnostics, hearing aids, and what the postcard introduces as “listening therapy”. You give this postcard to the patient on the first visit, usually at the time of the hearing test. It serves as a roadmap and “plants the seed” in the patient’s mind that he or she and you, together, are embarking on a hearing healthcare journey. It is also a great way of explicitly explaining why your practice is different from the competition. On the second or third visit, during the hearing aid assessment or the hearing aid fitting, you give the patient the second piece, which is a simple brochure that describes auditory brain training and its benefits. This piece may also serve as a brochure for the office. Here I like to think that we are fertilizing the seed that we planted with the postcard. We usually do not start the auditory training program on the day of fitting because many patients want a week or two to learn how to handle their devices. For some patients, who might not be one hundred percent satisfied at first, the promise of auditory brain training is also a way for you to say, “Don’t worry, your journey isn’t finished yet.” Finally, on the follow-up visit, you provide the “get started” piece, which is a simple handout that covers the basics of accessing the program online and making sure the computer is ready to go. The patient is not surprised that additional work is necessary to reap the benefits of the new hearing aids because you have created appropriate expectations during the previous visits. You give the patient a subscription code and the patient starts with the first lesson. Although certainly not necessary, we do offer orientation sessions via telephone to audiologists, which can be scheduled via email. More information about clEAR can be found at www.clearworks4ears.com. Good luck!
Barcroft, J., Sommers, M., & Tye-Murray, N. (2007). What learning a second language might teach us about auditory training. Seminars in Hearing, 28,150-160.
Barcroft, J., Spehar, B., Tye-Murray, N., & Sommers, M. (2016). Task-and talker-specific gains in auditory training. Journal of Speech, Language, and Hearing Research, 59(4), 862-870.
Boothroyd, A. (2008). CasperSent: A program for computer-assisted speech perception testing and training at the sentence level. Journal of the Academy of Rehabilitative Audiology 41, 31-52.
Humes, L.E., Burk, M.H., Strauser, L.E., & Kinney, D.L. (2009). Development and efficacy of a frequent-word auditory training protocol for older adults with impaired hearing. Ear and Hearing, 30(5), 613.
Kraus, N., & White-Schwoch, T. (2015). Unraveling the biology of auditory learning: A cognitive sensorimotor-reward framework. Trends in Cognitive Science, 19, 642-654.
Lin, F.R., Metter, E.J., O’Brien, R.J., Resnick, S.M., Zonderman, A.B., & Ferrucci, L. (2011). Hearing loss and incident dementia. Archives of Neurology, 68(2), 214-220.
Moore, D.R., Rosenberg, J.F., & Coleman, J.S. (2005). Discrimination training of phonemic contrasts enhances phonological processing in mainstream school children. Brain and Language, 94(1), 72-85.
Sommers, M.S., Tye-Murray, N., Barcroft, J., & Spehar, B. (2015). The effects of meaning-based auditory training on behavioral measures of perceptual effort in individuals with impaired hearing. Seminars in Hearing, 36(4), 263-272.
Taylor, B. (2018). Getting ahead of the curve, part 1: Four cornerstones of a fee-for-service clinic. Hearing Review, 25(3) 16-20.
Tye-Murray, N. (in press). Foundations of aural rehabilitation: Children, adults, and their family members (5th Ed.). San Diego, CA: Plural Publishing.
Tye-Murray, N., Sommers, M.S., Mauzé, E., Schroy, C., Barcroft, J., & Spehar, B. (2012). Using patient perceptions of relative benefit and enjoyment to assess auditory training. Journal of the American Academy of Audiology, 23(8), 623-634.
Tye-Murray, N. (2018). 20Q: A perfect storm for auditory brain training. AudiologyOnline, Article 24001. Retrieved from www.audiologyonline.com